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First-ever head injury guidelines for children
While the guidelines were devised primarily for emergency department clinicians, experts say they can also offer direction for GPs.
Four percent of all childhood presentations in emergency departments are for head injuries.
‘At a national level, 4% of all children who present to emergency departments [EDs] are for head injuries.
‘So I wouldn’t be surprised if, in the right setting, it was similar numbers [in general practice].
‘These are very high numbers.’
That is Professor Franz Babl, Group Leader of Emergency Research at the Murdoch Children’s Research Institute and Professor of Paediatric Emergency Medicine at the University of Melbourne.
Dr Peter Baquie, a GP turned sports and exercise physician, told newsGP he agrees that minor head injuries are ‘very common’ in general practice.
A typical example is when a parent rings their GP after a baby has rolled off a change table to ask for further advice.
‘They’re minor household events, but of course they are incredibly anxiety provoking for a parent,’ he said.
Despite the prevalence of mild to moderate head injuries in children, there has been no national guidelines for the management of this issue – until now.
On 3 February, the first ever national guidelines, developed by the Paediatric Research in Emergency Departments International Collaborative (PREDICT) were published in Emergency Medicine Australasia.
Lead researcher Professor Babl told newsGP the target audience for the guideline is emergency physicians and staff.
‘But it does clearly spill over into areas that are in the same field, whether it’s ambulance services or GPs, both in terms of the triage beforehand and the discharge recommendations [after],’ he said.
In fact, he says that throughout the development of the guidelines, his team received input and feedback from a range of other medical bodies and specialists including the RACGP, radiologists, neurosurgeons, GPs and ambulance representatives.
The guidelines address 33 key clinical questions and contain 71 recommendations, along with an imaging/observation algorithm.
‘There is a drop-down [box] with the headings that clinicians need to be aware of, and they can just click on that and get the recommendations,’ Professor Babl said.
Each recommendation is classified according to whether it is new (created by the guideline working group), or adopted or adapted from existing guidelines.
In circumstances where there was limited or no evidence, Professor Babl says consensus-based guidelines were developed instead.
Examples of new recommendations include:
- children with ‘trivial’ head injury do not need to attend hospital for assessment and can be safely managed at home
- in all children presenting with mild to moderate head injury, the possibility of abusive head trauma should be considered
- children aged less than two with a suspected or identified isolated, non-displaced, linear skull fracture should have a medical follow-up within 1–2 months to assess for a growing skull fracture.
Professor Babl says the guidelines were primarily devised to help clinicians decide when to use imaging for mild to moderate head injuries.
‘The main purpose of the guidelines is to strike the correct balance between, on one hand, doing enough CT scans in order to not miss any intracranial injuries, and on the other hand, to not do any CT scans that would increase the radiation burden of children,’ he said.
‘We know that the radiation burden is particularly problematic in children under 10 and particularly in children under five, so the younger the kids are, the more problematic the CT scans.
‘We’re trying to work out that balance.’
Lead researcher Professor Franz Babl says that until now there have been no national guidelines on treating head injuries in children.
While that issue may seem less relevant to urban GPs, as emergency department clinicians manage such presentations, Dr Baquie says it is particularly relevant for rural GPs.
‘With country hospitals now having easier access to CTs than they had half-a-dozen years ago, it becomes particularly important in that rural facility … to have criteria in managing that sort of injury,’ he said.
Professor Babl says the new guidelines also address the question of whether children with an underlying bleeding disorder or similar condition require imaging automatically.
‘So, what you do with a child who has a bleeding disorder or has a ventricular shunt and they have a head injury,’ he said.
‘Do they automatically need a CT scan? Well, they don’t. It’s really trying to put the evidence together as much as possible.’
The guidelines also include information on post-discharge recommendations.
‘In essence, it provides guidance on what clinicians should tell parents and kids in terms of return to sports, return to school, what to look out for and when to have follow up, and who to have follow up with,’ Professor Babl said.
Dr Baquie welcomes such guidance.
He says the guidelines will have a significant impact on aiding health professionals managing mild to moderate head injury – and follow up – in children, particularly when it comes to common issues such as when to resume contact sport post-concussion.
‘[For] doctors to have guidelines around that, [it] just takes away a little bit of that anxiety that is understandably associated with the more general fears and concerns about concussion in the long term,’ Dr Baquie said.
Professor Babl would like the guidelines to be used to ensure a national unified response to mild to moderate head injuries in children.
‘What we are hoping is that the guidelines will be incorporated into hospital guidelines and clinicians can use them directly as well,’ he said.
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