What are the guidelines for managing head injuries in pediatric patients?

Pediatric Head Injury Management Guidelines

Initial Assessment and Risk Stratification

For children presenting with head trauma to the emergency department, use validated clinical decision rules to guide neuroimaging decisions rather than routine imaging, and focus on identifying high-risk features that predict clinically important traumatic brain injury. 1

Key Assessment Components

• Assess mental health symptoms (both pre-existing and new) and identify modifiers that may delay recovery using clinical risk scores to predict prolonged symptoms 1
• Do NOT use biomarkers (such as S100B or GFAP) outside of research settings for diagnosis of pediatric mild traumatic brain injury 1
• Evaluate for severe headache, especially when associated with other risk factors, as this warrants observation and potential CT imaging 1
• Monitor for worsening symptoms during observation period, as acutely deteriorating headache requires emergent neuroimaging 1

Neuroimaging Decisions

Skull radiographs should NOT be used for diagnosis or screening for intracranial injury in pediatric mild traumatic brain injury. 1

When to Image

• Consider head CT only when intracranial injury is suspected based on validated clinical decision-making rules (such as PECARN), not for routine concussion diagnosis 1
• Obtain emergent neuroimaging for children with acutely worsening symptoms during observation 1
• Consider cervical spine CT only when cervical spine injury is specifically suspected 1

Critical Pitfall

The 2024 systematic review found no evidence-based recommendations in high-quality guidelines for repeat imaging, neurosurgical consultation timing, or hospital admission criteria—these decisions must rely on clinical judgment and institutional protocols 1

Acute Management: The First 24-48 Hours

Recommend a period of relative rest for 24-48 hours immediately following acute mild traumatic brain injury, but avoid strict prolonged rest exceeding 3 days as this worsens outcomes. 1, 2

What "Relative Rest" Means

• Permit activities of daily living including walking and other symptom-limited physical and cognitive activities as tolerated 1
• Implement "cognitive rest" with temporary reduction in school workload, avoidance of video games, computer use, television, and loud music 2
• Use acetaminophen for symptom management; avoid NSAIDs/aspirin due to theoretical bleeding risk 2
• Remove immediately from play—"When in doubt, sit them out!" 2

Discharge Education (Mandatory Components)

Healthcare providers MUST inform families about warning signs, expected recovery course, symptom monitoring, activity management, and clear follow-up instructions. 1

Required Discharge Counseling Elements

• Warning signs of more serious injury requiring immediate return 1
• Description of injury and expected course of symptoms and recovery 1
• Instructions on monitoring postconcussive symptoms 1
• Prevention of further injury 1
• Management of cognitive and physical activity/rest 1
• Return to play/recreation and school instructions 1
• Use validated prediction rules for persistent symptoms to provide prognostic counseling 1

Return to Activity Protocol (After Initial 24-48 Hours)

Begin gradual progressive return following a specific stepwise protocol, with each step requiring minimum 24 hours before progression. 2

The Six-Step Protocol

1. Light aerobic exercise (walking, swimming, stationary cycling at <70% maximum heart rate) 2
2. Sport-specific exercise (skating drills, running drills—no head impact) 2
3. Non-contact training drills (progression to more complex drills, may start progressive resistance training) 2
4. Full-contact practice (following medical clearance, participate in normal training) 2
5. Return to competition 2

Progression Rules

• If symptoms recur, return to previous asymptomatic level and rest 24 hours before attempting progression again 2
• Supervised, non-contact aerobic exercise below symptom threshold is particularly beneficial for adolescents 2
• Allow return to full activity only when the individual has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion 2

Management of Persistent Symptoms (Beyond 10 Days)

Implement multidisciplinary management for symptoms persisting beyond 10 days, with referral to traumatic brain injury specialist if symptoms persist beyond 3 weeks. 2

Evidence-Based Interventions

• Sub-symptom threshold aerobic exercise (primary intervention) 2
• Vestibular rehabilitation for persistent vestibular dysfunction 2
• Cervical physical therapy and manual therapy for neck pain when present 2
• Vision therapy for oculomotor dysfunction 2
• Cognitive behavioral therapy for psychological symptoms 2

What NOT to Use

Do NOT routinely use vestibular suppressants like meclizine or benzodiazepines—these medications show no benefit as definitive primary treatment, may interfere with central compensation mechanisms, and can decrease diagnostic sensitivity during examination 2

Critical Pitfalls to Avoid

• Never allow same-day return to play after diagnosed concussion 2
• Do not return to play while taking medications for concussion symptoms, as this indicates incomplete recovery 2
• Avoid high-intensity physical activity during recovery as this is detrimental 2
• Be more conservative with younger athletes (<18 years) due to potential catastrophic effects on the maturing brain 2
• Do not rely solely on patient-reported symptoms without objective assessment 2

Special Considerations for Severe Head Injury

For children with severe traumatic brain injury (Glasgow Coma Scale ≤8), management requires intensive care with intracranial pressure monitoring, aggressive treatment of elevated ICP, and multidisciplinary neurocritical care 3, 4. These patients require immediate neurosurgical consultation and are beyond the scope of mild traumatic brain injury guidelines.