American Academy Of Pediatrics

AMERICAN ACADEMY OF PEDIATRICS

The Management of Minor Closed Head Injury in Children

Committee on Quality Improvement, American Academy of Pediatrics

Commission on Clinical Policies and Research, American Academy of Family Physicians

ABSTRACT. The American Academy of Pediatrics

(AAP) and its Committee on Quality Improvement in

collaboration with the American Academy of Family

Physicians (AAFP) and its Commission on Clinical Poli-

cies and Research, and in conjunction with experts in

neurology, emergency medicine and critical care, re-

search methodologists, and practicing physicians have

developed this practice parameter. This parameter pro-

vides recommendations for the management of a previ-

ously neurologically healthy child with a minor closed

head injury who, at the time of injury, may have experi-

enced temporary loss of consciousness, experienced an

impact seizure, vomited, or experienced other signs and

symptoms. These recommendations derive from a thor-

ough review of the literature and expert consensus. The

methods and results of the literature review and data

analyses including evidence tables can be found in the

technical report. This practice parameter is not intended

as a sole source of guidance for the management of

children with minor closed head injuries. Rather, it is

designed to assist physicians by providing an analytic

framework for the evaluation and management of this

condition. It is not intended to replace clinical judgment

or establish a protocol for all patients with a minor head

injury, and rarely will provide the only appropriate ap-

proach to the problem.

The practice parameter, “The Management of Minor

Closed Head Injury in Children,” was reviewed by the

AAFP Commission on Clinical Policies and Research and

individuals appointed by the AAFP and appropriate

committees and sections of the AAP including the Chap-

ter Review Group, a focus group of office-based pedia-

tricians representing each AAP District: Gene R. Adams,

MD; Robert M. Corwin, MD; Diane Fuquay, MD; Bar-

bara M. Harley, MD; Thomas J. Herr, MD, Chair; Ken-

neth E. Matthews, MD; Robert D. Mines, MD; Lawrence

C. Pakula, MD; Howard B. Weinblatt, MD; and Delosa A.

Young, MD.

The supporting data are contained in a technical report

available at http://www.pediatrics.org/cgi/content/full/

104/6/e78.

ABBREVIATIONS. AAP, American Academy of Pediatrics; AAFP,

American Academy of Family Physicians; CT, cranial computed

tomography; MRI, magnetic resonance imaging.

Minor closed head injury is one of the most frequent

reasons for visits to a physician.

1

Although

.

95 000

children experience a traumatic brain injury each

year in the United States,

2

consensus is lacking about

the acute care of children with minor closed head

injury. The evaluation and management of injured

children may be influenced by local practice cus-

toms, settings where children are evaluated, the type

and extent of financial coverage, and the availability

of technology and medical staffing.

Because of the magnitude of the problem and the

potential seriousness of closed head injury among

children, the AAP and the American Academy of

Family Physicians (AAFP) undertook the develop-

ment of an evidence-based parameter for health care

professionals who care for children with minor

closed head injury. In this document, the term Sub-

committee is used to denote the Subcommittee on

Minor Closed Head Injury, which reports to the AAP

Committee on Quality Improvement, and the AAFP

Commission on Clinical Policies, Research, and Sci-

entific Affairs.

While developing this practice parameter, the Sub-

committee attempted to find evidence of benefits

resulting from 1 or more patient management op-

tions. However, at many points, adequate data were

not available from the medical literature to provide

guidance for the management of children with mild

head injury. When such data were unavailable, we

did not make specific recommendations for physi-

cians and other professionals but instead we pre-

sented a range of practice options deemed acceptable

by the Subcommittee.

An algorithm at the end of this parameter presents

recommendations and options in the context of di-

rect patient care. Management is discussed for the

initial evaluation of a child with minor closed head

injury, and the disposition after evaluation. These

recommendations and options may be modified to fit

the needs of individual patients.

PURPOSE AND SCOPE

This practice parameter is specifically intended for

previously neurologically healthy children of either

sex 2 through 20 years of age, with isolated minor

closed head injury.

The parameter defines children with minor closed

head injury as those who have normal mental status

at the initial examination, who have no abnormal or

focal findings on neurologic (including fundoscopic)

examination, and who have no physical evidence of

The recommendations in this statement do not indicate an exclusive course

of treatment or serve as a standard of medical care. Variations, taking into

account individual circumstances, may be appropriate.

PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad-

emy of Pediatrics.

PEDIATRICS Vol. 104 No. 6 December 1999

1407

skull fracture (such as hemotympanum, Battle’s sign,

or palpable bone depression).

This parameter also is intended to address chil-

dren who may have experienced temporary loss of

consciousness (duration

,

1 minute) with injury,

may have had a seizure immediately after injury,

may have vomited after injury, or may have exhib-

ited signs and symptoms such as headache and leth-

...