Pediatric Head Trauma (Head Injury in Children)

What is Pediatric Head Trauma (Head Injury in Children)?

Traumatic brain injury (TBI) is a major reason for death and disability in children between the ages 1 to 18. It happens when a blow to the head disrupts the normal functioning of the brain. The severity of TBI is often categorized as mild, moderate, or severe, using a system called the Glasgow Coma Scale (GCS). Mild TBI has a GCS score of 14 to 15, moderate has a score of 9 to 13, and severe has a score of 3 to 8. Children with severe TBI face a high risk of death and lasting neurological problems.

TBI can be thought of as an initial injury happening at the time of the blow, followed by a secondary injury due to various factors like internal bleeding in the brain, insufficient blood flow, swelling, spasms in the blood vessels, and low oxygen levels. Every year, TBI in children leads to more than 500,000 emergency department visits and nearly 60,000 hospital stays in the United States. Boys are more susceptible to TBI than girls in all age groups. By implementing prevention strategies, preventing subsequent neurological injury, setting up organized trauma systems, and promptly recognizing and treating high pressure in the brain, the harmful effects of severe TBI can be lessened. These efforts can, in turn, help to reduce the rates of long-term health problems and death among children.

What Causes Pediatric Head Trauma (Head Injury in Children)?

Several factors can contribute to traumatic brain injuries (TBI) in children. This includes sports, falls, and car accidents. Falls causing head injuries are particularly common in young children due to their under-developed walking skills, larger heads in comparison to their bodies, high center of gravity, and weaker neck muscles.

Another less common, but serious cause of TBIs in children, is non-accidental trauma. This refers to injuries inflicted intentionally, not from accidents, and it’s something that medical professionals need to be aware of.

Risk Factors and Frequency for Pediatric Head Trauma (Head Injury in Children)

Every year, over 500,000 emergency department visits and about 60,000 hospitalizations are attributed to pediatric Traumatic Brain Injury (TBI) in the United States. While many of these cases involve minor injuries like scrapes on the scalp, some are quite severe. In fact, trauma is the leading cause of death in children older than a year, with more than 3,000 child deaths per year due to head injuries. It’s also worth noting that boys are more likely than girls to experience TBI.

Each year, pediatric TBI leads to over 500,000 emergency room visits and about 60,000 hospital stays in the United States.
Most of these cases are minor injuries, like scrapes on the scalp.
However, some head injuries in children are severe, and they’re the leading cause of death in children over 1 year old.
More than 3,000 child deaths per year are due to head injuries.
Boys are more likely to experience TBI than girls.

Signs and Symptoms of Pediatric Head Trauma (Head Injury in Children)

During the initial check of a child with a traumatic brain injury (TBI), doctors will systematically look for all injuries. This process also involves stabilizing the child’s heart rate and promoting proper blood flow to the brain. Part of this initial survey involves a quick neurological examination using the Glasgow Coma Scale (GCS).

The pediatric GCS is similar to the adult version, but the verbal component varies based on the child’s age group. For example, in children aged 0-23 months, a score ranges from “babbling, cooing, or smiling appropriately” (5 points) to “no verbal response” (1 point). In children aged 2-5, scores range from “articulating appropriate words and phrases” (5 points) to “no verbal response” (1 point). GCS in school-age children (>5 years) is similar to the adult scale.

Once any issues with the child’s airways, breathing, or blood circulation have been addressed, a detailed head-to-toe physical examination is carried out. During this process, doctors look for hidden injuries and pay attention to a few key signs and symptoms:

Checking for problems with the cranial nerves, bruising around the eyes or behind the ears, cerebrospinal fluid (CSF) leakage from nose or ear, or a blood-filled eardrum (signs of base of skull fracture).
Eye examination for bleeding at the back of the eye (which could indicate child abuse) and swelling of the optic disk (a sign of increased pressure inside the skull).
Feeling the scalp for blood clots, unusual crackling sensation, cuts, and abnormalities in the shape of the skull (indications of skull fractures). In babies, a full or tense soft spot on the head might also indicate increased pressure inside the skull.
Listening for abnormal sounds in the carotid arteries, signs of Horner syndrome, or unusual sensations in the face or neck (signs of a tear in the carotid or vertebral artery).
Checking for tenderness in the spine, numbness, inability to control urination, weakness in the limbs, or involuntary erection (signs of spinal cord injury).
Testing of motor and sensory function in the limbs (for signs of spinal cord injury).
Checking reflexes, including plantar reflexes for upgoing toes (Babinski sign). Clonus, Hoffman reflex, and bulbocavernosus reflex are concerns for associated spinal cord injury.

Non-accidental trauma (NAT) should be suspected if a child presents with certain classic features such as multiple injuries in different locations that are in different stages of healing, retinal hemorrhage, bilateral chronic subdural hematomas in a young child, or serious neurological injury with minimal signs of external trauma.

Pediatric patients with a TBI might display symptoms like headache, nausea, vomiting, irritability, and double vision, among other symptoms. Depending on the severity of the TBI, as children grow up, they may struggle with processing information, reasoning, impulsivity, mood instability, and sleep disturbances.

Testing for Pediatric Head Trauma (Head Injury in Children)

Repeated neurological exams are key in identifying patients with elevated pressure in their brain, allowing for earlier treatment. A CT scan without contrast is the main imaging method used for patients with a traumatic brain injury who also have an abnormal Glasgow Coma Scale (GCS) score. There are established guidelines that help doctors decide if certain children can safely avoid a CT scan, even if they show normal or nearly normal GCS scores.

The PECARN algorithm, a set of guidelines, provides these recommendations for getting a CT scan for a child who has suffered a mild traumatic brain injury with a low risk of serious brain injuries:

For Children aged 2 or younger:

If the child has a GCS score below 14, a discernible skull fracture, or any other signs of altered mental status, a CT scan is recommended.
If the child lost consciousness for 5 seconds or longer, has a severe injury, a scalp hematoma, or isn’t acting as they usually would according to their parent or guardian, a CT scan may be considered. Whether it’s performed depends on factors like the age of the child, whether their condition worsens, the presence of any isolated findings, and the experience of the doctor.
CT scans aren’t recommended for kids in this age group who don’t meet the previous criteria.

For Children aged 2 or older:

If the child has a GCS score of 14 or less, shows signs of basilar skull fracture or has other signs of altered mental status, a CT scan is recommended.
If the child has lost consciousness, has a severe headache, has vomited, or has a severe injury, a CT scan may be considered or observation may be used (similar to the criteria for younger children).
CT scans aren’t recommended for kids in this age group who don’t meet the previous criteria.

While CT scans are effective for initially evaluating a traumatic brain injury, there’s little evidence to suggest that regular repeated scans are beneficial for children. If the clinical picture remains unclear after a CT scan or if the patient’s neurological status hasn’t improved after several days in the hospital, an MRI may be helpful. Imaging of the brain vessels, such as CT angiography (CTA) or magnetic resonance angiography (MRA) might be used if there’s concern about a vessel injury, or an underlying abnormality such as a malformation or aneurysm. Additionally, an eye examination is important to check for the presence of bleeding in the retina in suspected cases of non-accidental trauma (NAT).

Treatment Options for Pediatric Head Trauma (Head Injury in Children)

When a patient can’t maintain an open airway or achieve sufficient oxygen levels with extra oxygen, airway devices might be required. Continuous monitoring of oxygen and ventilation levels is essential. The aim is to reach a particular level of carbon dioxide in the air exhaled by the patient. In the first 48 hours, it is key to avoid causing a low carbon dioxide level through over-ventilation. In cases where the patient’s consciousness level is very low, an endotracheal tube might be used to secure the patient’s airway. In traumatic brain injury situations, low blood pressure can negatively affect the prognosis, so isotonic solutions can be used to prevent/correct low blood pressure.

Post-traumatic seizures are often associated with severe traumatic brain injuries. Using the anti-seizure drug, phenytoin, for 7 days after severe injury can decrease early occurrence of post-traumatic seizures, but it doesn’t affect late post-traumatic seizures. Levetiracetam, another epilepsy drug, could also be beneficial but isn’t as well-researched as phenytoin.

In children, persistent high intracranial pressure (pressure inside the skull) is related to poor neurological results. Besides controlling high intracranial pressure, maintaining a minimum level of cerebral perfusion pressure (the pressure needed to supply the brain with blood) is important to reduce mortality and improve neurological outcomes. Children’s intracranial pressure and cerebral perfusion pressure thresholds can be different from adults due to age.

Ways to reduce high intracranial pressure include positioning the patient correctly, ensuring the neck isn’t obstructing blood flow, administering appropriate painkillers and sedatives, and careful ventilation. Intracranial pressure monitoring might be necessary in infants and children with severe traumatic brain injuries whose neurological status can’t be reliably assessed. Certain medications that draw water out of the brain tissue might be used to reduce intracranial pressure.

In some cases, barbiturates (a type of sedative) might be given to help lower high intracranial pressure by reducing the brain’s energy demand. A type of surgery called decompressive hemicraniectomy might be required where a part of the skull is removed to reduce pressure. Neither induced cooling of the body nor warming is beneficial in children with brain injuries. Shunting of cerebrospinal fluid, through external ventricular or lumbar draining might be necessary in certain situations. It’s worth noting that corticosteroids do not improve neurological outcomes and can lead to increased systemic complications.

A complete check-up from head to toe is crucial to look out for hidden injuries or different causes of the symptoms. Patients with a condition known as Glutaric Aciduria type 1 may have symptoms like a larger than normal head size and fluid accumulation on both sides of the brain. These signs could be wrongly interpreted as resulting from non-accidental trauma or NAT.

What to expect with Pediatric Head Trauma (Head Injury in Children)

About 90% of patients with head injuries can usually go home from the emergency room. According to CT scans upon admission, around 1% of patients with mild to moderate head injury severity have a significant injury inside the skull.

For those with severe head injuries, current data shows that mortality rates could be anywhere between 20% and 39%. Among patients who sustain non-accidental trauma, the most common cause of death is abusive head trauma (commonly known as shaken baby syndrome).

Helping professionals predict the outcomes after a head injury through research has been a major focus. This is important for doctors, researchers, and the families of patients. The International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) study has contributed greatly to our understanding of head injury outcomes and can be found online.

Possible Complications When Diagnosed with Pediatric Head Trauma (Head Injury in Children)

Complications following a head injury can range from minor disruptions in thinking skills to more serious conditions like seizures, lasting nervous system damage, and even death. People who suffer a severe head injury might also experience complications all over the body. Some of these are due to not being able to move around, and might include lung infections, blood clots in the deep veins, and blockages in the lung. If patients struggle to breathe without a machine, they might need a temporary or permanent breathing tube and feeding tube.

Possible complications to consider:

Mild cognitive impairment
Seizures
Long-term neurological deficits
Death
Pneumonia (from immobility)
Deep venous thrombosis (from immobility)
Pulmonary embolus (from immobility)
Need for a tracheostomy (breathing tube)
Need for a gastrostomy tube (feeding tube)

Preventing Pediatric Head Trauma (Head Injury in Children)

If your child experiences a head injury, it’s important to know the warning signs of increased pressure in the brain (ICP). Before any surgical procedures are done, if needed, doctors should explain all the possible short-term and long-term complications. It’s essential that you understand and agree to these possible outcomes before the surgery is carried out.

Frequently asked questions

Pediatric head trauma, also known as head injury in children, refers to a blow to the head that disrupts the normal functioning of the brain. It is a major cause of death and disability in children between the ages of 1 to 18. The severity of pediatric head trauma is categorized as mild, moderate, or severe based on the Glasgow Coma Scale (GCS) score.

Pediatric head trauma is quite common, with over 500,000 emergency department visits and about 60,000 hospitalizations attributed to it in the United States each year.

Signs and symptoms of Pediatric Head Trauma (Head Injury in Children) include: - Headache - Nausea - Vomiting - Irritability - Double vision - Bruising around the eyes or behind the ears - Cerebrospinal fluid (CSF) leakage from nose or ear - Blood-filled eardrum (signs of base of skull fracture) - Bleeding at the back of the eye (which could indicate child abuse) - Swelling of the optic disk (a sign of increased pressure inside the skull) - Blood clots, unusual crackling sensation, cuts, and abnormalities in the shape of the skull (indications of skull fractures) - Full or tense soft spot on the head in babies (indicating increased pressure inside the skull) - Abnormal sounds in the carotid arteries, signs of Horner syndrome, or unusual sensations in the face or neck (signs of a tear in the carotid or vertebral artery) - Tenderness in the spine, numbness, inability to control urination, weakness in the limbs, or involuntary erection (signs of spinal cord injury) - Motor and sensory function abnormalities in the limbs (signs of spinal cord injury) - Reflex abnormalities, including upgoing toes (Babinski sign), clonus, Hoffman reflex, and bulbocavernosus reflex (concerns for associated spinal cord injury) - Multiple injuries in different locations that are in different stages of healing - Retinal hemorrhage - Bilateral chronic subdural hematomas in a young child - Serious neurological injury with minimal signs of external trauma It is important to note that depending on the severity of the traumatic brain injury (TBI), children may also experience long-term difficulties with processing information, reasoning, impulsivity, mood instability, and sleep disturbances as they grow up.

Several factors can contribute to traumatic brain injuries (TBI) in children. This includes sports, falls, car accidents, and non-accidental trauma.

A doctor needs to rule out the following conditions when diagnosing Pediatric Head Trauma (Head Injury in Children): 1. Discernible skull fracture 2. Altered mental status 3. Loss of consciousness for 5 seconds or longer 4. Severe injury 5. Scalp hematoma 6. Abnormal behavior compared to usual 7. Signs of basilar skull fracture 8. Severe headache 9. Vomiting 10. Signs of non-accidental trauma (NAT) 11. Glutaric Aciduria type 1

The types of tests that may be needed for Pediatric Head Trauma (Head Injury in Children) include: - CT scan without contrast: This is the main imaging method used for patients with a traumatic brain injury who have an abnormal Glasgow Coma Scale (GCS) score. - MRI: If the clinical picture remains unclear after a CT scan or if the patient's neurological status hasn't improved after several days in the hospital, an MRI may be helpful. - CT angiography (CTA) or magnetic resonance angiography (MRA): These imaging tests might be used if there's concern about a vessel injury or an underlying abnormality such as a malformation or aneurysm. - Eye examination: An eye examination is important to check for the presence of bleeding in the retina in suspected cases of non-accidental trauma (NAT).

In the treatment of pediatric head trauma, several approaches are taken. It is important to control high intracranial pressure and maintain a minimum level of cerebral perfusion pressure to improve neurological outcomes and reduce mortality. This can be achieved through proper positioning of the patient, ensuring unobstructed blood flow in the neck, administering appropriate painkillers and sedatives, and careful ventilation. In some cases, medications that draw water out of the brain tissue may be used to reduce intracranial pressure. Barbiturates, a type of sedative, can be given to lower high intracranial pressure by reducing the brain's energy demand. Decompressive hemicraniectomy, a surgical procedure where a part of the skull is removed, may be necessary to reduce pressure. Induced cooling or warming of the body is not beneficial in children with brain injuries. Shunting of cerebrospinal fluid through external ventricular or lumbar draining might be required in certain situations. It is important to note that corticosteroids do not improve neurological outcomes and can lead to increased systemic complications.

The possible side effects when treating Pediatric Head Trauma (Head Injury in Children) include: - Mild cognitive impairment - Seizures - Long-term neurological deficits - Death - Pneumonia (from immobility) - Deep venous thrombosis (from immobility) - Pulmonary embolus (from immobility) - Need for a tracheostomy (breathing tube) - Need for a gastrostomy tube (feeding tube)

The prognosis for pediatric head trauma varies depending on the severity of the injury. For mild to moderate head injuries, about 90% of patients can usually go home from the emergency room. However, for severe head injuries, the mortality rates can range from 20% to 39%. It is also worth noting that among patients who sustain non-accidental trauma, the most common cause of death is abusive head trauma.

A pediatrician or a pediatric neurologist.