Management of Pediatric Head Trauma Under 2 Years with Normal CT
For a child under 2 years old with a history of fall, loss of consciousness, and a normal CT scan, observation is appropriate with specific discharge criteria and clear return precautions. 1
Risk Stratification After Normal CT
The key question is whether this child met intermediate-risk or very low-risk PECARN criteria before the CT was obtained:
Very Low-Risk Criteria (Can Safely Discharge)
Children under 2 years with all of the following can be safely discharged after normal CT 1:
- GCS of 15
- Normal mental status
- No palpable skull fracture
- No nonfrontal scalp hematoma
- Loss of consciousness ≤5 seconds
- No severe mechanism of injury
- Acting normally per parents
These very low-risk children have a <0.02% risk of clinically important traumatic brain injury with 100% sensitivity and 100% negative predictive value validated in over 4,000 children. 1
Intermediate-Risk Criteria (Consider Admission for Observation)
Children under 2 years with GCS 15 and normal mental status but with 1:
- Loss of consciousness >5 seconds
- Severe mechanism of injury
- Not acting normally per parent
These children have approximately 0.9% risk of significant injury. 1 With a normal CT scan, the decision between discharge versus continued observation depends on parental comfort level, ability to monitor at home, proximity to medical care, and presence of multiple risk factors. 1
Observation Protocol
If Discharging Home After Normal CT
Provide explicit return precautions for 2:
- Worsening or severe headache
- Repeated vomiting
- Increasing drowsiness or difficulty arousing
- Seizure activity
- Weakness or numbness
- Confusion or unusual behavior
- Clear fluid from nose or ears
Telephone follow-up within 24 hours is useful for both patients and physicians to assess clinical status. 2
If Admitting for Observation
Monitor for 1:
- Changes in mental status
- Development of focal neurological signs
- Worsening headache
- Persistent vomiting
- Any clinical deterioration
Clinical deterioration in a patient with initially normal examination warrants immediate repeat CT imaging. 3
Critical Pitfalls to Avoid
Do not assume a normal CT scan at presentation excludes all intracranial pathology—abnormal findings may appear several hours after injury, particularly in infants. 2 This is why observation (either inpatient or with reliable home monitoring) remains important even after normal imaging.
In children under 1 year old, maintain a lower threshold for admission given the difficulty of observational assessment in young infants. 1 Parental ability to monitor and proximity to emergency care should factor heavily into the discharge decision.
If there is any concern for non-accidental trauma, do not discharge—these children require full evaluation including skeletal survey and social work consultation regardless of normal head CT. 1 Subdural hemorrhage in a non-mobile infant is highly concerning for abuse. 4
Ensure parents understand that "normal CT" does not mean "no injury occurred"—it means no injury requiring immediate intervention was detected. 2 Clear communication about what symptoms warrant return is essential, as clinical observation after injury may be more important than the initial CT in infants. 2