TBI is the leading cause of acquired disability in children Neurologic and cognitive deficits are related to patient age at time of injury, severity of injury, and degree of structural injury Unique considerations should be given to children with shunt-dependent hydrocephalus and bleeding diatheses or platelet disorders, such as hemophilia Clinical Considerations (See Also Chapter 41 Injury: Head ) Clinical Recognition The historical and physical features of TBI encompass a wide spectrum of signs and symptoms For a detailed review of signs and symptoms, please review Chapter 41 The presentation of infants may be nonspecific and include poor feeding, vomiting, irritability, a bulging anterior fontanelle, altered mental status defined as a Pediatric Glasgow Coma Score of less than or equal to 14 ( Table 113.1 ), lethargy, seizure and presence of scalp hematoma and/or depression Typical complaints in children include headache, progression of headache with increasing severity, vomiting, confusion, altered mental status defined as a Glasgow Coma Scale (GCS) of less than or equal to 14 ( Table 113.1 ), seizure, lethargy, focal neurologic abnormality, obtundation, or signs of a basilar skull fracture, such as Battle sign, periorbital ecchymosis hemotympanum, and cerebral spinal fluid (CSF) otorrhea or rhinorrhea Signs of impending cerebral herniation include altered mental status, pupillary changes, bradycardia, hypertension, and respiratory depression Recent clinical decision rules to assist in the determination for emergent radiography have stratified ciTBI risk based on key historical and physical examination features The clinical decision rules are applied to two separate patient populations, children less than years of age and children years of age and greater Children less than years of age provide a unique challenge to the clinician as they commonly present after minor trauma but may be asymptomatic or clinical assessment may be difficult Additionally, the clinician must always have a low index of suspicion for nonaccidental trauma, as the incidence of child abuse in this age group is high Head injury accounts for the highest mortality in nonaccidental or intentional injury For a detailed review of inflicted injuries, please refer to Chapter 87 Child Abuse/Assault