Managing Head Trauma in Children
More than 30 years ago, my toddler stood up in his stroller, evading the various belts and restraints, and took a dramatic header down onto the pavement. He cried right away — a good thing, because it meant he didn’t lose consciousness, and by the time we got home, he seemed to be consoled, though he was already developing a major goose egg. I was a fourth-year medical student at the time and called the pediatric practice at University Health Services, and explained, somewhat frantically, that I was due to get on a flight to California with him in a couple of hours; I was going out for my all-important residency interviews.
No problem, said the sympathetic doctor on call, all those years ago. You’re a medical student, you must have a penlight. Just take it along on the plane, and make sure you wake your son up every two hours and check that his pupils are equal, round and reactive to light. And he wished me good luck at my interviews. I hung up, much comforted. It was not until we were sitting on the airplane, me with my penlight in my pocket, that it occurred to me to wonder what I was supposed to do if somewhere over the Midwest, his pupils were not equal, round and reactive.
We’ve gotten better, I hope, at some of the advice we give, but for pediatricians and for parents, head trauma in children is still an occasion for difficult decision making. Unlike broken limbs, usually detected because of pain and clearly diagnosed with X-rays, head injuries are tricky to diagnose and manage. In many cases where the concern is concussion, there is no medication or surgery that can make a difference — the primary treatment is rest. Public awareness over the ties between concussions and later problems for children, and publicity about chronic traumatic encephalopathy in athletes may be making parents even more anxious about treating head injuries.
But with increasing concern in recent years about the radiation risk to children of CT scans, doing a head CT just to reassure a worried parent — or even a worried doctor — is generally seen as bad medicine; if you’re giving a child a significant dose of possibly dangerous radiation, you need to have some evidence that you may actually be doing something necessary for that child’s safety.
That evidence was carefully collected in emergency rooms around the country linked together in the Pediatric Emergency Care Applied Research Network, or Pecarn. They collected data from 2004 to 2006, enrolling 34,000 children with “minor-to-moderate” blunt head trauma — those bangs and bumps on the head that are not clearly devastating. From the study, they were able to devise algorithms, clinical guidelines for managing children after head trauma. Essentially these algorithms ask doctors to check for a number of factors, according to the child’s age, which put children at higher risk of traumatic brain injury (loss of consciousness, for example, or not acting normally, or severe headache or vomiting), and if none of those factors are present, the data suggest that no head CT is needed. Plenty of children still fall into a gray area, which is why emergency rooms often observe for long periods of time before making these decisions.
The guidelines were implemented in pediatric emergency rooms. But Dr. Rebecca Jennings, a pediatric hospitalist at Seattle Children’s Hospital and assistant professor of pediatrics, wanted to encourage their use in community hospitals as well.
She and her colleagues designed an education project to try to reduce unnecessary head CTs on children, reaching out both to E.R. doctors and to general pediatricians in the community. “We wanted to emphasize to the generalists that they should be referring patients for evaluation of their head trauma and not for a head CT,” Dr. Jennings said. It’s important for doctors to help parents understand, she said, that “part of the evaluation is observation.”
Dr. Jennings was the first author on a study published this year in the journal Pediatrics, in which an education program offered by a children’s hospital reduced the CT scan rate to 17.4 percent from 29.2 percent.
“A head CT does not diagnose concussion,” Dr. Jennings said. “The head CT is to look for a brain bleed or a skull fracture primarily, and so often with these families the E.R. physician will say, yes, your child did have a concussion and give concussion counseling, but your child is well enough that we think the risk of having a brain bleed or skull fracture is quite low.”
Mind you, even for the children whose head trauma is clearly more serious — the children who do need to get head CTs, and whose head CTs actually show some evidence of injury, a similar set of complicated decisions looms. The good news is that even these children will mostly do very well (again, we aren’t talking here about children with devastating injuries).
Dr. Jacob Greenberg, a neurosurgical resident at Washington University, St. Louis, said that the issue for neurosurgeons managing these hospitalized patients with known traumatic brain injury is still, “is there something really scary going on that we’re missing?” With Dr. David Limbrick, the chief of pediatric neurosurgery at Washington University School of Medicine as senior author, a multidisciplinary group published a study in JAMA Pediatrics earlier this year in which they looked only at children who had evidence of traumatic brain injury on head CT scans, and who were therefore mostly being sent to intensive care. “The impression we had was the vast majority of these kids were doing fine,” Dr. Greenberg said. “Did they really have to go to the I.C.U.?”
When they looked closely at how these children were being managed, he said, they found that there was not necessarily a close correlation between whether the children were at high risk and whether they were in fact getting I.C.U. monitoring.
Again, they developed a risk scale — this one taking into account the head CT findings — and were able to show that together with the child’s general neurological status, such findings as a depressed skull fracture or a shift in the midline of the brain on CT allowed them to identify the children at higher risk, who really belonged in the I.C.U.
In an email, Dr. Greenberg said that the hope was that this risk score will be viewed as a tool to aid — rather than replace — physician judgment in caring for these children. “These management decisions are complex and we don’t want our work to minimize the role of a thoughtful physician evaluating an individual child,” he wrote. “Rather, we hope that this score will help give a stronger evidence-based foundation to the decisions that physicians make and potentially help reduce some of the variations in practice that we found.”
Head injuries in children scare everyone, from parents to neurosurgeons. If I had taken my toddler to the emergency room, three decades ago, he might well have gone for head imaging for no other reason than that his mother was in medical school and worried. It’s taken great time and care to bring the weight of evidence to these decisions, and the result, for most parents and children nowadays, should be some greater degree of comfort and reassurance.