Concussion Evaluation and Management in Young Children

Immediate Red Flags Requiring Emergency Evaluation

The American Academy of Pediatrics recommends seeking immediate medical evaluation for children under 2 years of age with altered mental status or Glasgow Coma Scale (GCS) score of 14 or less, as this carries approximately 4.4% risk of clinically important brain injury 1, 2, 3, 4, 5
A palpable skull fracture is a high-risk feature that requires immediate medical assessment and possible CT imaging, as recommended by the American College of Radiology 1, 2, 3, 4, 5
Nonfrontal scalp hematoma, or a bump on the side or back of the head, is a significant risk factor for serious injury and warrants immediate medical evaluation, according to the Journal of the American College of Radiology 1, 2, 3, 4, 5
Loss of consciousness greater than 5 seconds is a high-risk feature that necessitates immediate medical attention, as stated by the American Academy of Pediatrics 1, 2, 3, 4, 5
Severe mechanism of injury, such as a motor vehicle collision or fall from significant height, requires immediate medical evaluation, as recommended by the American College of Radiology 1, 2, 3, 4, 5
If a child is not acting normally according to their parent, this is a significant concern that warrants immediate medical attention, as stated by the American Academy of Pediatrics 1, 2, 3, 4, 5

The American Academy of Pediatrics recommends medical evaluation or close observation for children with loss of consciousness between 5 seconds and several minutes, as this carries approximately 0.9% risk of significant injury 4, 5
Vomiting, especially if multiple episodes, is an intermediate-risk feature that requires medical evaluation or close observation, according to the Journal of the American College of Radiology 1, 2, 3
Severe or worsening headache is a concerning symptom that necessitates medical evaluation or close observation, as stated by the American Academy of Pediatrics 1, 2, 3
If a child is not acting normally but still alert, this is an intermediate-risk feature that requires medical evaluation or close observation, as recommended by the American College of Radiology 4, 5

The American College of Radiology states that 18% of patients who deteriorate after head injury do so between days 2-7, and recommends seeking immediate medical attention if any critical warning signs develop, such as worsening headache, repeated vomiting, or increasing confusion or disorientation 5
Unusual drowsiness or difficulty waking, seizures, weakness or numbness, unequal pupil size, slurred speech, or significant behavior changes are all critical warning signs that require immediate medical attention, as stated by the American Academy of Pediatrics 5

The American Academy of Pediatrics recommends that age under 2 years is itself a risk factor for more serious injury, making careful evaluation particularly important in this age group 1, 2, 3
The Journal of the American College of Radiology states that CT imaging should not be routinely obtained for all head injuries due to radiation exposure risks, but CT remains the imaging modality of choice when clinically indicated, as it rapidly identifies bleeding and fractures without requiring sedation 1, 2, 3, 6

The American College of Radiology recommends that children under 2 years old with a fall and loss of consciousness be immediately assessed using PECARN criteria to stratify risk, with very low risk criteria including GCS=15, no palpable skull fracture, no nonfrontal scalp hematoma, LOC ≤5 seconds, no severe mechanism, and acting normally per parents, allowing them to safely forgo CT imaging 7, 8
Children under 2 years with a GCS of 15, no palpable skull fracture, and no severe mechanism of injury are considered very low risk, with a <0.02% risk of clinically important traumatic brain injury, and may safely forgo CT evaluation, as validated in over 4,000 children with 100% sensitivity and 100% negative predictive value 7, 8

The American College of Radiology recommends CT head without contrast as the imaging modality of choice for high-risk children, as it rapidly identifies bleeding and fractures without requiring sedation 8
The American College of Radiology advises against routinely obtaining skull radiographs, as up to 50% of intracranial injuries occur without fracture, and radiographs miss many fractures that CT would detect 7, 8
The American College of Radiology also advises against using MRI, CTA, MRA, or conventional angiography for initial evaluation, as there is no evidence supporting these modalities in acute minor head trauma, and MRI is impractical 7, 8

Intermediate-risk children have a 0.9% risk of clinically important brain injury, and CT may be considered based on parental preference, multiple risk factors present, worsening symptoms during observation, or young infant age where observational assessment is challenging 8
High-risk children have a 4.4% risk of clinically important brain injury, and CT head is indicated 7, 8