Falling Off the Bed, But Avoiding the CAT Scan
By Barbara Lock, MDOctober 02, 2009
I am a little ashamed to admit that when my third child was a little baby, he fell off of the bed and hit his head on the hard wooden floor three separate times. He also fell down some stairs when he was one, fell off of a slide when he was two, and has fallen off of chairs, benches, swings, curbs, toilets, strollers and bathtubs at various times in his young life. He's none the worse.
I am a little ashamed, though, because he's the third child, and we're not new parents. We should have figured this stuff out by now. Many of these falls happened when I was not around, like the time he inched his way off of the bed in front of my husband, hit his head, vomited, and then cried for half an hour continuously. I was informed four hours later when I came home from work. He was fine. He still meets his developmental milestones, like lying to his parents ("Did you poop in your pull-up?" "No"), drawing on the wall in permanent marker, and refusing to eat anything green, yellow, red, purple, blue, or orange, unless artificially so.
So when I see little kids in the Emergency Department who have fallen off of beds and down stairs, and the parents ask me if their child needs a CT scan, I can say quite truthfully and with great assurance: I wouldn't do it if it were my kid.
Many kinds of medical tests, CT scans included, are not without risks. CT scans deliver radiation, and exposing a growing brain to radiation without a very good reason is just asking for trouble. In fact, researchers from Columbia Presbyterian Medical Center (now NewYork Presbyterian Hospital) estimate that approximately one out of 1400 children who are exposed to the radiation dose of the average head CT will develop fatal brain cancer above and beyond their baseline risk. That's a great reason to avoid a head CT in a kid unless you really think there is a disaster lurking.
Luckily, evidence has been accumulating for years that most kids that bonk their head don't need CT scans at all. The ones that do are usually pretty sick. Doctors have known since 2003 that only kids with one or more of a certain set of clinical findings will have a chance of having a disaster on CT scan - and even most of those kids' CT scans will still be fine. These criteria have been refined, rederived and validated, and their most recent iteration is published this month in the Lancet.
For this study, researchers from 25 pediatric emergency departments who participate in the Pediatric Emergency Care Applied Research Network (PECARN) collected information about 42,412 children who had bonked their head and were acting pretty much normal in the emergency department (Glascow Coma Scale 14 or 15). A little more than a third of these patients had a CT of the head, and only 376 (0.9%) had clinically important brain injury, or brain injury that required doctors to do something about it. Only 60 patients (0.1%) required neurosurgery. Researchers were able to look at the cases of children who had clinically important brain injury and figure out the clinical clues that doctors could use to predict which kids might benefit from a CT scan and which ones would never or nearly never benefit.
For children age 2 and under, those who were acting normally according to the parents, and who seemed normal to the doctor, who had no collection of blood under the scalp on the sides or back of the head, who had no loss of consciousness or loss of consciousness for less than 5 seconds, who had a non-severe injury mechanism (like falling off of a bed), and who had no palpable skull fracture, were ALL fine on CT scan. The likelihood that a kid who looks that good could be the one who turns out to have clinically important brain injury is infinitessimally small (literally: negative likelihood ratio infinitely close to zero).
Doctors who are able to effectively explain this reasoning to worried parents could prevent thousands of unneccesary head CTs, and possibly prevent scores or hundreds of brain tumors in children down the line. It's not easy; many doctors cave in to the pressure and order the test. But I wouldn't if it were my kid.
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