When it comes to evaluating children who have experienced traumatic brain injury, we try to accurately identify those with serious head injury while also protecting them from unneeded cranial radiation exposure. However, this is trickiest for the youngest children, as it is often difficult to clinically ascertain serious injury, and these children are at highest risk for injury from radiation.
This week, Pediatrics is early releasing an article by Dr. Todd Lyons and colleagues at Boston Children’s Hospital, entitled “Emergency Department Evaluation of Young Infants with Head Injury,” which is a retrospective look at nearly 125,000 children younger than 2 years of age who presented with isolated head injury in 2015–2019 to one of 47 US pediatric emergency departments (10.1542/peds.2023-065037).
The authors report that, compared to children 3–24 months of age, those who were <3 months of age were:
- Almost 3 times more likely to have cranial imaging
- 9 times more likely to be diagnosed with clinically important traumatic brain injury
- More likely to be diagnosed with skull fracture
- More likely to be evaluated for abusive head trauma
- More likely to be admitted to the hospital
- More likely to need neurosurgery
These youngest infants were also more likely to die from their injuries.
Given all of these increases in likelihood of serious injury, the authors conclude that the radiation exposure is worth the risk—we don’t want to miss any of these diagnoses. However, there is also much variability with regard to how these youngest infants are evaluated. They recommend more research to develop protocols to assist clinicians in evaluating these infants.
In an invited commentary entitled, “Cranial Imaging in the Youngest Infants: Worth the Risk,” Drs. Audrey Raut and Mary Clyde Pierce from Lurie Children’s Hospital agree with the authors’ conclusions that the radiation exposure is worth the risk in these youngest infants (10.1542/peds.2023-065511). They also importantly point out that we don’t want to miss a diagnosis of child physical abuse, citing studies that demonstrate that one-third of infants and young children with abusive head trauma are initially misdiagnosed.
While we do not want to be cavalier in our use of radiologic studies, when there is a “cannot miss” diagnosis, we need to proceed with the necessary evaluation.
