Paediatric traumatic brain injury: an approach in primary care

Clinical assessment

When primary care physicians are faced with managing paediatric head injuries, tapping on their main tools – history and physical examination – is key.

The physician should first identify those who require immediate management at the Children’s Emergency. Box 1 shows the clinical assessment sequence used to identify these patients, which is based on various clinical decision rules such as the National Institute for Health and Care Excellence guidelines and the Paediatric Emergency Care Applied Research Network (PECARN) algorithm.(12-15)

Box 1

Patients who require immediate management at the Children’s Emergency:

Clinical guideline tool

As seen in Box 1, most paediatric TBIs are mild.(11) However, 1% of these tend to be clinically important TBIs (ciTBI), which are defined as the presence of an intracranial injury on computed tomography (CT) associated with neurosurgical intervention, endotracheal intubation for the management of head injury, and hospitalisation directly related to the head injury for at least 48 hours and/or death.(15)

To safely identify children with low risk for ciTBIs who do not require neuroimaging, the PECARN algorithm(15) is a well-validated paediatric head injury clinical decision rule that primary care physicians can use. It has a sensitivity of 100.0% and 96.8% in children below two years of age and those aged two years or older, respectively. Further, it has negative predictive values of 100.00% and 99.95%, respectively. Although the PECARN algorithm has not been validated in the local context, it has been validated in various countries, all producing similar results. The algorithm can be accessed online (https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm).

Other tools such as the Canadian Assessment of Tomography for Childhood Head Injury and Children’s Head injury ALgorithm for the prediction of Important Clinical Events are widely recognised. The PECARN algorithm was selected because, in comparative studies, its algorithm had the highest sensitivity(16) in identifying patients with TBI who required CT imaging as well as validation,(17) particularly for those with minor head trauma.

Management

The primary care physician should be able to manage the majority of mild TBIs, since only a minority are ciTBIs. Skull radiographs should not be ordered, as they have no role in neuroimaging, except as part of the skeletal survey for non-accidental injury, which is usually conducted in a tertiary hospital.

Based on the PECARN algorithm, physicians who decide to observe their patients need to do so for 4–6 hours. As this would not be practical in the primary care setting, they could decide to either send their patient to the Children’s Emergency or back home in the presence of a reliable caregiver, where rest and observation for 24–48 hours are key.(18) If the latter is chosen, advice on red flags and future injury prevention (e.g. ensuring that younger children are not left alone on high beds or sofas and are instead placed on floor beds or cots, or wearing seat restraints in vehicles and helmets when cycling) must be provided, either in the form of pamphlets or website links (e.g. https://www.cdc.gov/headsup/index.html). These points are to be documented in clinical notes as well. In addition, a follow-up call and scheduled appointment should be arranged.(19) Learning from the COVID-19 situation, telemedicine consultations may also be adopted, as they provide further visual clinical assessment and a sense of reassurance to the physician and the caregiver.(20)

Children who sustain concussions should be advised not to return to playing sports or doing physical activity on the same day in order to avoid the risk of second impact syndrome. A strategy of gradual return to physical or cognitive activities should be adopted, whereby activities are gradually increased in a stepwise manner as long as the patient remains asymptomatic.(4,5,21) Students returning to school with residual symptoms may benefit from certain accommodations such as being offered a lighter workload and more frequent breaks, and being excused from loud places such as the canteen or assemblies.(5,22) On follow-up, if there are persistent symptoms with inability to resume normal activities within 2–4 weeks,(5) such as post-concussion syndrome (PCS), follow-up with a paediatric neurologist is recommended. Children at risk of PCS include those with a personal history of mood disorders, psychiatric illnesses or migraine.(23)

Special consideration – non-accidental injury

Suspicion of NAI must always be differentially considered by the primary care physician. This is especially so if the history from the informant or caregiver is inconsistent or does not match the degree of injury; or if physical examination reveals poor hygiene, malnutrition, growth restriction, multiple cutaneous bruises of different ages, suspicious pattern injuries, burn marks and skeletal injuries at different stages of healing(24) (although the latter cannot be clinically ascertained in the primary care setting).

If an NAI is suspected, the patient should be referred to the Children’s Emergency via ambulance or police escort. In Singapore, police notification must be done. As primary care physicians, we must ensure the safety of the child. The role of primary care physicians in child abuse is to ensure the safety of the at-risk child who cannot protect himself from abuse and to notify the police so that timely investigations can be performed and action can be taken to prevent further harm.