Assessment and Management of Delayed Presentation After Pediatric Head Injury
At one month post-injury, acute imaging and emergency evaluation are no longer indicated; instead, focus on assessing for persistent post-concussive symptoms using validated symptom rating scales and providing symptom-based management if needed. 1
Current Clinical Assessment (One Month Post-Injury)
Symptom Evaluation
Use an age-appropriate, validated symptom rating scale to assess for persistent post-concussive symptoms, as recommended by the CDC for children 6 years and older. 1 Appropriate tools include:
Assess specifically for these symptom domains: 2
Key Clinical Questions to Ask
- Is the child experiencing any ongoing symptoms such as headaches, dizziness, difficulty concentrating, behavioral changes, or sleep problems? 1, 3
- Has the child returned to normal activities including school, play, and physical activities without symptom exacerbation? 4
- Are there any progressive or worsening symptoms that have developed over the past month? 5
When Imaging Would Have Been Indicated Acutely (For Context)
While imaging is not indicated now at one month, understanding what would have warranted acute evaluation helps assess the initial injury severity:
High-Risk Features (Would Have Required CT) 5, 6
- Glasgow Coma Scale ≤14 or altered mental status (4.4% risk of clinically important brain injury) 5
- Palpable skull fracture 5
- Loss of consciousness >5 seconds 5
- Severe mechanism of injury 5
- Not acting normally per parent 5
Very Low-Risk Features (Would Not Have Required CT) 5, 6
- GCS=15, normal mental status 5
- No palpable skull fracture 5
- Loss of consciousness ≤5 seconds 5
- No severe mechanism 5
- Acting normally per parents 5
Important note: Skull radiographs should never be used for concussion diagnosis or screening, as they have only 63% sensitivity for skull fractures and cannot detect intracranial injuries. 1
Management at One Month Post-Injury
If Symptoms Are Present
- Provide symptom-based management targeting the specific domains affected (physical, cognitive, mood, sleep). 2
- Implement graduated return to activities including cognitive and physical activity with progressive return to school and play. 4
- Monitor for persistent symptoms beyond 3 months, as most children resolve by 3-6 months post-injury, though a minority have persistent deficits. 3
If Symptoms Have Resolved
- Reassure the family that the child has recovered appropriately. 1
- Educate about future head injury prevention and the importance of immediate evaluation if another head injury occurs. 1
Critical Pitfalls to Avoid
- Do not obtain CT imaging at this delayed timepoint unless new concerning symptoms develop, as acute intracranial complications would have manifested within the first week. 7
- Do not use biomarkers (such as S100B or tau protein) outside of research settings for diagnosis. 1
- Do not dismiss persistent symptoms as purely psychological; post-concussive syndrome has well-documented organic basis with neuropathologic, neurophysiologic, and neuroimaging abnormalities. 3
- Recognize that age <2 years is a risk factor for more serious injury, though this child at age 6 falls outside this highest-risk group. 5
Red Flags Requiring Immediate Re-Evaluation
Seek immediate medical attention if any of these develop: 5