Does Your Child Have a Serious Head Injury? This Simple Tool Will Help You Decide.

The Problem

As parents, we’ve all been there. Maybe our child fell and hit their head, maybe they tumbled down the stairs. Or perhaps they were playing football and there was a hard hit to the head.

We’re worried, especially when we see a big goose egg forming, or when they have other symptoms such as dizziness or nausea. But does your child need to be seen in the emergency department? Do they need imaging of the brain – a CT scan – to look for a brain bleed?

I get it. When you are confronted with this situation as a parent, you just want to know that your child is all right.

You want to know that nothing bad is going to happen the rest of the day or night. It seems like doing a CT scan is easy so why not just do it to know that everything is ok.

There are a number of problems with this.

First, CT scans are expensive. If providers ordered CT scans on every patient with a head injury, the costs would be much higher than they already are.

Plus, this would back up emergency departments, slowing them down when there are already super long waits.

If this is not enough, CT scans use radiation to obtain images. There is evidence that this radiation increases the lifetime risk of cancer, such as leukemia, brain tumors, and thyroid cancer.

It is estimated that 1 in 1500 children who get a CT scan will go on to develop cancer at some point later in life. In fact, in children the risk is 10 times higher than in adults.

In medicine, providers weigh the risks against the benefits of a test or procedure. In this case, we are weighing the risk of cancer from radiation versus the risk of a major brain injury. This seems like a tall order. Doesn’t this require considerable training?

The Solution

The good news is that this issue has been extensively researched. And there are guidelines that you and your doctors can follow. In medicine, these are known as the Pediatric Emergency Care Applied Research Network (PECARN) guidelines for head injury in children.

These are simple rules that give plenty of information and can determine the risk that your child has a potential serious injury.

They are fairly easy to follow and I will do my best to be as clear as I can regarding the different risk factors associated with more serious injury.

Kids younger than 2 years old

Your kid should be evaluated by a physician if:

• They are persistently confused or not acting like themself.
• You think their skull bone may be broken (generally a soft boggy spot on the head).
• They lost consciousness (passed out) for more than 5 seconds.
• They have a large bump (goose egg) anywhere other than their forehead – the forehead is generally ok and normally not anything to worry about.
• The cause of the head injury was high impact like a fall from considerable height (general rule of thumb is greater than 3 feet) or a high speed car accident.

Kids older than 2 years old

Your kid should be evaluated by a physician if:

• They are persistently confused or not acting like themself.
• You think their skull bone may be broken (severe bruising on the skull, around the eyes, or behind the ears, or significant bleeding).
• They lost consciousness (passed out) for any time period.
• They have any vomiting.
• They have a severe headache.
• The cause of the head injury was high impact like a fall from considerable height (general rule of thumb is greater than 3 feet) or a high speed car accident.

Any of these risk factors should prompt a visit immediately to the primary doctor or to the ER.

Those without these risk factors generally have a very low risk of serious brain injury.

Suffice it to say that a child with low risk who is less than 2 years old has less than 0.02% chance of having a clinically important (serious) brain injury.

And those 2 years old or greater who are low risk have a less than 0.05% chance of a clinically important (serious) brain injury.

This is really amazing information from a huge study. Though each child is unique and no one wants that 1 child out of 1000 to be theirs, the evidence is very conclusive that CT imaging of the brain should not be performed on a number of children with minor head injuries.

Conclusion

The next time your child has a head injury, take a look at the risk factors above to assess your child’s risk. Using the PECARN decision rule can help guide and inform you regarding the next step and whether your child needs to see a doctor immediately.

Understand that if there is any concern or doubt about whether your child may have any of the risk factors above or you are just plain concerned, the safest thing to do is go directly to the ER.

We deserve the best for our children and should have the chance to participate in shared and informed decision making in any clinical setting. Many times, the best recommendation is observation and reassurance.

This article should help you better understand head injury risk in children. What do you think, should doctors be following these guidelines? Does this article change your mind about the proper use of CT scans in child head injuries? Comment below.