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PEDIATRICS Vol. 107 No. 5 May 2001, pp. 983-993

Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines

Received Apr 28, 2000; accepted Sep 1, 2000.

Sara A. Schutzman*, Patrick BarnesDagger , Anne-Christine Duhaime§, David Greenes*, Charles Homerparallel , David Jaffe, Roger J. Lewis#, Thomas G. Luerssen**, and Jeff SchunkDagger Dagger

From the * Division of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, Massachusetts; Dagger  Pediatric Neuroradiology, Lucile Salter Packard Children's Hospital, Stanford University Medical School, Palo Alto, California; the § Division of Neurosurgery, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; the parallel  Division of General Pediatrics, Children's Hospital, Harvard Medical School, Boston, Massachusetts; the  Division of Emergency Medicine, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri; the # Department of Emergency Medicine, Harbor-UCLA Medical Center, UCLA School of Medicine, Torrance, California; the ** Division of Neurosurgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana; and the Dagger Dagger  Division of Emergency Medicine, Primary Children's Medical Center, University of Utah School of Medicine, Salt Lake City, Utah.

Objective.  In children <2 years old, minor head trauma (HT) is a common injury that can result in skull fracture and intracranial injury (ICI). These injuries can be difficult to detect in this age group; therefore, many authors recommend a low threshold for radiographic imaging. Currently, no clear guidelines exist regarding the evaluation and management of head-injured infants. We sought to develop guidelines for management based on data and expert opinion that would enable clinicians to identify children with complications of HT and reduce unnecessary imaging procedures.

Methods.  Evidence: References addressing pediatric HT were generated from a computerized database (Medline). The articles were reviewed and evidence tables were compiled. Expert Panel: The multidisciplinary panel was comprised of nine experts in pediatric HT.Consensus Process: A modified Delphi technique was used to develop the guidelines. Before the one meeting, panel members reviewed the evidence and formulated answers to specific clinical questions regarding HT in young children. At the meeting, guidelines were formulated based on data and expert consensus.

Results.  A management strategy was developed that categorizes children into 4 subgroups, based on risk of ICI. Children in the high-risk group should undergo a computed tomography (CT) scan. Those in the intermediate risk group with symptoms of possible ICI should either undergo CT scan or observation. Those in the intermediate risk group with some risk for skull fracture or ICI should undergo CT and/or skull radiographs or observation. Those in the low-risk group require no radiographic imaging.

Conclusions.  We have developed a guideline for the evaluation of children <2 years old with minor HT. The effect of these guidelines on clinical outcomes and resource utilization should be evaluated.  Key words:  children, minor head trauma, evaluation, management, guidelines.




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