From the Guidelines
When examining an infant for traumatic brain injury (TBI), look for both external signs and neurological abnormalities, prioritizing the assessment of the Glasgow Coma Scale, pupillary response, and vital signs, as these are crucial indicators of the severity of the injury 1.
Key Examination Findings
- Check for scalp hematomas, bruising, lacerations, or skull depressions which may indicate trauma
- Assess the fontanelles - a bulging fontanelle suggests increased intracranial pressure
- Examine pupillary response, as unequal or unreactive pupils may indicate serious brain injury
- Monitor vital signs, particularly for bradycardia and irregular breathing patterns which can signal increased intracranial pressure
- Observe for altered consciousness, irritability, lethargy, or difficulty waking
- Infants with TBI may demonstrate poor feeding, vomiting, or seizures
- Check for posturing (abnormal flexion or extension of limbs) and assess tone and reflexes
- Be vigilant for retinal hemorrhages which may suggest abusive head trauma
Importance of the Glasgow Coma Scale
The Glasgow Coma Scale, modified for pediatrics, helps evaluate consciousness level, with a score of 14 or 15 indicating a minor head injury, but still requiring careful assessment for potential complications 1.
Unique Considerations in Infants
Infants have unique anatomical features, including open fontanelles and thinner skulls, which affect how TBI presents compared to older children or adults, making physical examination findings crucial in this age group 1.
High-Risk Factors
High-risk factors for intracranial injury from minor head trauma in children <2 years of age include those with a GCS of 14, other signs of altered mental status, or signs of any palpable skull fracture, with an estimated risk of clinically significant intracranial injury of approximately 4.4% 1.
From the Research
Exam Findings in Infant TBI
When examining an infant with a traumatic brain injury (TBI), several factors should be considered:
- The Glasgow Coma Scale (GCS) score, which is used to assess the severity of the injury 2, 3
- The presence of intracranial hemorrhage or skull fracture, which can indicate a more severe injury 2, 3
- The mechanism of injury, such as a fall from furniture or a stroller, which can affect the severity of the injury 2
- The infant's age, as younger infants may be more vulnerable to injury 4
Imaging Studies
Imaging studies, such as computed tomography (CT) scans or X-rays, may be necessary to assess the extent of the injury:
- A low threshold for CT scans is recommended in infants under 3 months due to their vulnerability to minor blunt head trauma 2
- X-ray examinations should be avoided, and unnecessary CT scans should be reduced to minimize radiation exposure 2
Predictors of Outcome
Several factors can predict the outcome of an infant with TBI:
- Younger age, which can be a risk factor for an unfavorable outcome 4
- Mechanism of injury, such as a motor vehicle collision, which can affect the severity of the injury 4
- Presence of seizures, which can indicate a more severe injury 4
- Intracranial pressure monitoring, which can help guide treatment decisions 5
Treatment Thresholds
Treatment thresholds for infant TBI may vary depending on the individual case and the clinician's choice: