More than 30 years ago, my toddler stood up in his stroller, evading the various belts and restraints, and took a dramatic header down onto the pavement. He cried right away — a good thing, because it meant he didn’t lose consciousness, and by the time we got home, he seemed to be consoled, though he was already developing a major goose egg. I was a fourth-year medical student at the time and called the pediatric practice at University Health Services, and explained, somewhat frantically, that I was due to get on a flight to California with him in a couple of hours; I was going out for my all-important residency interviews.
No problem, said the sympathetic doctor on call, all those years ago. You’re a medical student, you must have a penlight. Just take it along on the plane, and make sure you wake your son up every two hours and check that his pupils are equal, round and reactive to light. And he wished me good luck at my interviews. I hung up, much comforted. It was not until we were sitting on the airplane, me with my penlight in my pocket, that it occurred to me to wonder what I was supposed to do if somewhere over the Midwest, his pupils were not equal, round and reactive.
We’ve gotten better, I hope, at some of the advice we give, but for pediatricians and for parents, head trauma in children is still an occasion for difficult decision making. Unlike broken limbs, usually detected because of pain and clearly diagnosed with X-rays, head injuries are tricky to diagnose and manage. In many cases where the concern is concussion, there is no medication or surgery that can make a difference — the primary treatment is rest. Public awareness over the ties between concussions and later problems for children, and publicity about chronic traumatic encephalopathy in athletes may be making parents even more anxious about treating head injuries.
But with increasing concern in recent years about the radiation risk to children of CT scans, doing a head CT just to reassure a worried parent — or even a worried doctor — is generally seen as bad medicine; if you’re giving a child a significant dose of possibly dangerous radiation, you need to have some evidence that you may actually be doing something necessary for that child’s safety.
That evidence was carefully collected in emergency rooms around the country linked together in the Pediatric Emergency Care Applied Research Network, or Pecarn. They collected data from 2004 to 2006, enrolling 34,000 children with “minor-to-moderate” blunt head trauma — those bangs and bumps on the head that are not clearly devastating. From the study, they were able to devise algorithms, clinical guidelines for managing children after head trauma. Essentially these algorithms ask doctors to check for a number of factors, according to the child’s age, which put children at higher risk of traumatic brain injury (loss of consciousness, for example, or not acting normally, or severe headache or vomiting), and if none of those factors are present, the data suggest that no head CT is needed. Plenty of children still fall into a gray area, which is why emergency rooms often observe for long periods of time before making these decisions.