Elsevier

The Journal of Pediatrics

Volume 162, Issue 2, February 2013, Pages 392-397
The Journal of Pediatrics

Original Article
Pediatric Traumatic Brain Injury and Radiation Risks: A Clinical Decision Analysis

https://doi.org/10.1016/j.jpeds.2012.07.018Get rights and content

Objective

To determine the optimal imaging strategy for young children with minor head injury considering health-related quality of life and radiation risk. In children with minor head trauma, the risk of missing a clinically important traumatic brain injury (ciTBI) must be weighed against the risk of radiation-induced malignancy from computed tomography (CT) to assess impact on public health.

Study design

We included children <2 years old with minor blunt head trauma defined by a Glasgow Coma Scale score of 14-15. We used decision analysis to model a CT-all versus no-CT strategy and assigned values to clinical outcomes based on a validated health-related quality of life scale: (1) baseline health; (2) non-ciTBI; (3) ciTBI without neurosurgery, death, or intubation; and (4) ciTBI with neurosurgery, death, or intubation >24 hours with probabilities from a prospective study of 10 000 children. Sensitivity analysis determined the optimal management strategy over a range of ciTBI risk.

Results

The no-CT strategy resulted in less risk with the expected probability of a ciTBI of 0.9%. Sensitivity analysis for the probability of ciTBI identified 4.8% as the threshold above which CT all becomes the preferred strategy and shows that the threshold decreases with less radiation. The CT all strategy represents the preferred approach for children identified as high-risk.

Conclusion

Among children <2 years old with minor head trauma, the no-CT strategy is preferable for those at low risk, reserving CT for children at higher risk.

Section snippets

Methods

This study based on literature review was exempt from review by our Institutional Review Board. The authors constructed a decision analysis model for children younger than 2 years with blunt head trauma and a GCS score of 14-15 for 2 strategies: (1) CT all; or (2) no CT (ie, no immediate CT for any children, which is depicted in Figure 1 as square decision nodes). As shown in the decision tree, following the decision of obtaining a CT or not obtaining a CT, physicians will observe the outcome

Results

We find relatively high overall utilities due to the preponderance of children in the baseline health state (with or without CT), which for our study population is mostly perfect health. Overall, the no-CT strategy yields an expected utility of 0.991 and the CT-all strategy yields a utility of 0.985, which suggests that at the expected or prior probability of ciTBI for this population of 9:1000 [ie, p(ciTBI) = 0.9%], no CT represents the optimal strategy. Figure 2, A shows the sensitivity

Discussion

Our decision analysis model suggests that for children younger than 2 years with blunt head trauma presenting to the ED with GCS scores of 14-15, the no-CT strategy appears optimal based on an expected prior probability of ciTBI of 0.9% when considering health-related quality of life outcomes and the risk of radiation over time. This result occurs because cranial CT increases the lifetime risk of lethal malignancy for a child (based on a CT radiation dose of 2 mSv) and reveals a ciTBI in a

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    The authors declare no conflicts of interest.

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