Most childhood deaths and disabilities are associated with trauma. According to Kossmann & Raghupathi (2012), the United States (U.S.) records about 3000 infant deaths, 50,000 hospitalizations and approximately 700,000 emergency department visits each year. Minor head injuries, also referred to concussion is the trauma-induced alteration of brain functions that might or might not cause loss of consciousness in the affected person. Infants have higher chances of suffering from minor head injuries because they involve in various sporting activities that subject their heads to various types of forces. Head traumas occur mostly among children between the ages of 0 to 14 years. In developing countries, traumatic brain injury (TBI) is the most common cause of infant deaths and childhood disability. Young male children have higher chances of acquiring TBI. The most common cause of minor sport head injury is a blow to the head that occurs when a child falls while playing. The clinical approaches to children reported with this case are different depending on the impact of the blow. However, most clinicians recommend the patient to undergo a computed tomography (CT) imaging in order to determine the impact of the injury.
Most clinical specialists try to save excessive costs related to admission and unnecessary diagnostic tests by doing a quick screening with an assumption that the injury is minimal. Clinicians should accurately diagnose a child with any type of head injury and carryout and give the correct medication because an infant head is delicate and can lead to complications by ignoring a small problem. The head of an infant is proportionally larger in comparison with the body size.
Clinician’s aim in evaluating head trauma is to accurately identify and diagnose a patient whose life is a risk because of a serious head injury. Primary brain injuries demand early diagnosis and through treatment in order to prevent secondary injuries that are extremely dangerous. Infants who seem depressed and unconscious after a head injury present an easier diagnosis that those who are fully conscious because the evolving injury seems harder to identify.
Out of the many studies conducted on the prevalence of minor head injuries in the United States population, only 9.1% of the population aged between 0 to five years recorded most affects. The study carried out in 2012 showed that 1 out of 11 infants in U. S. are diagnosed with minor head injuries. A survey carried out by Schutzman (2013), showed that 4.7% of U.S. population suffered from ICI. In United Kingdom, 55% of minor head injuries occurred in children below the age of five years, with 28% younger than two years. Out of this population, male children accounted for 65% (Dunning et al, 2010).
Children with minor head injuries account t for 40-60% of traumatic brain injuries as seen on CT, with only an average of 4% of these scans giving positive results. In addition, clinically significant cases of radiographic intracranial injuries (ICIs) require close interventions such as incubation, hospital admissions or neurosurgery. Exposure to radiotherapy radiations has been associated with a lifetime risk of cancer. Younger children are at higher risks of acquiring cancer from exposure to head CT scan radiations because of high effective organ dose of radiation. Statistics show that approximately 20% of CT scan related cancer occurs to children under that age of 2 years (Stein et al, 2008). The healthcare department has introduced a rule requiring clinicians to make an accurate decision on children with head injuries who undergo a safe CT scan. See figure 1 and 2 below. The government introduced these rules of selective imaging infants and children because of the following. Firstly, there is a need to identify infants with clinically brain injuries that require early intervention. Secondly, there is a need to reduce unnecessary CT scan, surgeries and admissions (Palchak, 2004).
Figure 1: Estimated Organ-Specific Brain Radiation Dose for Head CT by Age (source: Brenner, 2007)
Figure 2: Estimated lifetime attributed risk of death from cancer because of head CT by age (Source: Brenner, 2007)
Most discussions about head traumas in children focus on sport-related injuries. The International Conference on Concussion in Sports (ICCS) is a body that conducts researches on various head injuries caused in sporting activities. The conferences held in 2001, 2004, and 2008 concluded that more than half of all head injuries were sport related. In U.S., about 10 young people suffer a fatal blow to the head, mostly caused by subdural hematoma. Studies show that most fatal head injuries occur due to extradural hematoma. Parents should be warned against allowing their children to return to play after a brain injury diagnosis because of the following. Firstly, the child’s full and fast recovery might be delayed because they require extra physical and cognitive rest. Secondly, a child might have trouble in concentrating and have slow reaction times that have the potential of exposing the child into higher risks of additional injuries. Finally, involvement in plays after a head injury might result into repeated injuries that eventually cause cumulative effects. A child who endures a second head impact while recovering from the first injury might lead into massive brain oedema resulting into high fatality rate.
Diagnoses approach to infants with minor head injuries
Young children pose a very challenging evaluation procedure because they have delicate bones and skins. In most cases, there are few or no clinical findings even with the use of CT scans. Almost 50% of infants suffer loss of consciousness after a head injury, but many have just a scalp hematoma upon physical examination. The probability of obtaining imaging studies increases with age. Moreover, the higher the number of signs and symptoms, the stronger the ability of obtaining imaging studies on patients. Advancement in technology has led into the introduction of newer imaging modalities, like the diffusion tensor imaging FMRI and PET scans. Once a child is taken to a doctor because of a blow in the head, the doctor examines him or her for any of the following:
- Memory and concentration
- Sensation and strength
In most cases, health experts recommend that a patient be observed overnight while in a hospital after a sporting accident. The following intermediate-risk factors may force the doctor to observe an infant for more than five hours:
- Vomiting that occur immediately after the injury
- If the child has history of lethargy or irritability
- Behavior change as recorded by the parent or guardian
- A skull fracture that is more than 24 hours old
- Loss of consciousness that occurs for a short time then it disappears
- Injury resulting from a big impact, such as a big head blow
Evaluating infants with minor head trauma mainly aims at identifying those suffering Traumatic Brain Injuries (TBI) in order to prevent progressive traumas. In addition, infants and children younger than 2 years of age should undergo a CT test if they show the following signs:
- Enlarged nonfrontal scalp hematomas, mostly occurs in children less than one year of age
- Nontrivial trauma that occurs to children less than three months
- Delayed vomiting by several hours after an accident has occurred, or frequent vomiting
- Presence of either any of the above intermediate-risk factors
On the other hand, skull radiographs are used to screen for a fractured bone in patients 3 to 24 months old and should be conducted by an experienced pediatric.
Management of minor head injuries starts by diagnosis. The most common symptoms of an infant suffering minor head injury are described in the following three groups:
- Cognitive problems:
The symptoms include impairment of short memory, confusion, amnesia, and loss of consciousness. For children who can speak, short, intermediate or long-term memory is tested with standardized questions. Examples of such questions are the type of team who were playing, the venue of the match, or the winners of the match.
- Physical symptoms
These include headache, vomiting, nausea, dizziness, ringing in the ears and visual disturbances.
- Physical signs
These include low level of consciousness, seizures, lack of coordination, slow in obeying commands, inappropriate or decreased play, slurred speech and inappropriate emotions.
Once any of the above signs are seen on a child, the doctor should take immediate measures in order to save the child from major injuries that occur because of delayed ICI treatments. The following are the recommended early management of a concussed child. Firstly, the child should be restricted of all physical activities. Cognitive rest is necessary with activities such as watching television, playing videos games, and reading should be avoided until the child symptoms eases. Moreover, educating children inform of explanation and reassurance combined with providing symptom-related information helps families cope with cases of head injuries and speed up recovery. Secondly, parents should avoid buying medicine in pharmacies without a doctor’s prescriptions to treat their injured infants. These include treatment of symptoms such as headaches. According to Camper et al (2005), pharmacological studies have failed to give clear evidence about the effectiveness of specific drugs for the treatment of minor head injuries without a CT scan. Although, sertraline manages concussion-related depression while dihydro-ergotamine manages concussion-related headaches a thorough confirmation is necessary before administering these drugs.