PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1231

Management of Minor Closed Head Injury in Children

To the Editor.

I would like to question a recommendation in "The Management of Minor Closed Head Injury in Children" practice parameter by the AAP's Committee on Quality Improvement.¹ In what is otherwise a very helpful compilation of the literature, the Committee recommends in the algorithm that fundoscopic examination be part of the neurologic examination of the child evaluated within 24 hours of head injury. I don't think that this recommendation is substantiated in any literature I could find published in English since 1970. My practice and teaching is that the performance of fundoscopy in acute head trauma is not warranted. An exception would be in the evaluation for "shaken baby syndrome."

The study by Steffen et al² prospectively examined the discs of 37 patients with monitored elevated intracranial pressures. Only 9 of these were traumatically induced, the rest produced by intracerebral bleeding. Only 1 of the patients developed papilledema and 3 others had fundus changes "considered to be a secondary sign of papilledema." The only papilledema occurred in a woman who died of a subarachnoid hemorrhage after failed clipping of an aneurysm. The time of occurrence is not stated. The other 3 developed fundoscopic changes on the fifth or sixth day.

The definitive study by Selhorst et al³ evaluated 426 patients after head injury. They found papilledema in 1 patient (with a GCS of 6 out of 15) on the day of injury. In another patient papilledema was discovered on the day of admission, but he had had his most recent injury 3 days previously and at operation had a chronic subdural. Another had changes on the second day and 12 others between days 3 and 199. They reference a 1929 study by Blakeslee showing "papillitis" in 18 of 610 patients with skull fracture that I do not have ready access to. In addition, papilledema was shown at autopsy by Lindenburg in a patient who died within 1 hour from head trauma.

I do not think that there is sufficient evidence that fundoscopy should be a recommendation in any algorithm for the immediate evaluation of head trauma. Its lack should not be construed as an inadequate neurologic examination by peers or particularly in a court of law.

Alan Jon Smally
Department of Traumatology and Emergency Medicine
University of Connecticut School of Medicine
Hartford Hospital
Hartford, CT 06102-5037

REFERENCES

1. American Academy of Pediatrics, Committee on Quality Improvement; American Academy of Family Physicians, Commission on Clinical Policies and Research The management of minor closed head injury in children. Pediatrics. 1999; 104:1407-1415 [Abstract/Free Full Text]
2. Steffen H, Birgit E, Aschoff A, The diagnostic value of optic disc evaluation in acute elevated intracranial pressure. Ophthalmology. 1996; 103:1229-1232 [Medline]
3. Selhorst JB, Gudeman SK, Butterworth JF, Papilledema after acute head injury. Neurosurgery. 1985; 16:357-363 [Medline]

In Reply.

Dr Smally raises concern that there is not sufficient evidence, as to value added, that fundoscopy should be recommended in the immediate evaluation of head trauma. In the guideline "The Management of Minor Closed-Head Injuries in Children," the AAP Committee on Quality Improvement states (in the algorithm notes), "This parameter addresses the management of previously neurologically healthy children with minor closed-head injury who have normal mental status on presentation, no abnormal or focal findings on neurologic (including fundoscopic) examinations, and no physical evidence of skull fracture, etc." This statement should not lead the reader to infer that all children presenting with minor head injury should undergo fundoscopic examination. But rather, when done as part of the physical evaluation of the minor head-injured child, the findings should be used as part of the process of evaluation and management.

Fundoscopic examination performed during the initial evaluation of a child with a recent minor head injury is a test with low sensitivity and limited predictive power when findings are negative. If fundoscopic examination is performed and papilledema or other signs of increased intracranial pressure are found, these findings should direct the practitioner toward increased diagnostic evaluations and appropriate management. As pointed out by Smally, the literature indicates that papilledema or eye signs of increased intracranial pressure are highly unusual in the first 24 hours after a head injury.

Given the minimal costs and limited time required to perform fundoscopy, common sense suggests that a fundoscopic examination should certainly not be discouraged as part of the physical examination. If a positive finding for increased intracranial pressure is observed, the result will be beneficial to the management of the child. If negative, as pointed out by Dr Smally, this finding alone should not completely reassure the examiner that a more serious problem is not present.

As written, the guideline does not recommend that fundoscopic examinations be performed on all children undergoing evaluation for minor head injury.

John B. Coombs
Chairperson for the Subcommittee on Minor Head Injury
for the AAP Committee on Quality Improvement
Department of Family Medicine and Pediatrics
University of Washington School of Medicine
Seattle, WA 98195

Robert Davis
Consultant to the AAP Subcommittee on Minor Head Injury